Axilla…The Neglected Entity
Any doctor of medicine worth his/her salt knows about the value of general physical examination. The physical examination of a patient is expected to begin with a ‘thorough’ general physical examination. The teachers make sure that this essential first step is drilled as deeply into the student’s psyche as they possibly can.
It appears that they indeed do succeed in implanting this concept fairly successfully but, for some inexplicable reason, this ‘essential’ link in the chain of an adequate physical examination tends to evaporate and at times disappear altogether with passage of time. ‘Mandatory’ turns into ‘cursory’ and finally (and sadly) even turn ‘unnecessary’ in the mindset of some clinicians.
Examination of lymph nodal regions is often included as part of the general physical examination. Every clinician would remember how many times he/she might have said ‘there is no generalized lymphadenopathy’ in his/her lineal case presentation as a student. Let us be frank; how many of us can touch our hearts and say that we did palpate the axillae before confidently pronouncing that ‘there is no generalized lymphadenopathy’?
At this stage, I must admit that I also (as a young doctor) belonged to the category of those who did not assess the axillae routinely for lymph nodes. Only belatedly did I realize the importance of this step. Once I began assessing the axillae in every case as a routine, I came across a fair number of individuals (of both sexes) who had significantly enlarged axillary lymph nodes with out lymph nodal enlargement in the other regions – those who would have been branded as having “no generalized lymphadenopathy”.
These patients had no obvious lesions in the drainage areas of the axillary lymph nodes. In fact this was the only positive clinical finding in a handful of them. Fine needle aspiration cytology in at least some of them gave us a firm diagnosis or led to a suspicion of tuberculosis in others. Would we have missed the diagnosis of tuberculosis forever? Perhaps not, I guess. These patients might have presented some months or years later with cervical lymphadenopathy or with some other sign/symptom of tuberculosis. It is simply the question of early diagnosis.
Axillary assessment for lymph nodes is unfailingly done for lesions for example, in the breast. But then, why is routine axillary palpation as a part of general physical examination is often neglected? The reasons could be manifold and may include – aesthetics, gender of the patient, being cumbersome, cultural factors or simply, plain indifference.
In conclusion, I suggest and strongly recommend that the assessment of the axillae must be stressed upon as an integral part of general physical examination. The teachers must lead by example. How a teacher routinely examines a patient is most likely to be accepted and followed by the students. The converse is also true. Students tend to watch what a teacher is doing the same way an examiner watches how a student examines a case in the examination.
In this digital age, the age of Godzilla and Mozilla, axilla has attained loads of exposure thanks to the cosmetics and perfume manufacturers. Why not, as clinicians, we devote part of our time to a routine digital assessment of the axillae?
Let us not allow the axillae to hide a diagnosis or two in their depths…..
About the Author: Dr. Aroon Kamath is a retired general surgeon from Father Muller Medical College, Mangalore, India as an Assistant Professor. He loves to teach, write for medical blogs and conduct medical quizzes. He can be reached at: [email protected]
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